A 43-year-old woman comes to the physician for a rash on her hands. The rash began 8-10 weeks ago. She moved to the community approximately 4 months ago and works as a nurse in the dialysis unit at a nearby hospital. The patient's past medical history is significant for hypertension treated with hydrochlorothiazide. She also takes naproxen regularly for headaches. Her hands are shown in the image below: Which of the following is the most likely diagnosis?

Question

A 43-year-old woman comes to the physician for a rash on her hands.  The rash began 8-10 weeks ago.  She moved to the community approximately 4 months ago and works as a nurse in the dialysis unit at a nearby hospital.  The patient's past medical history is significant for hypertension treated with hydrochlorothiazide.  She also takes naproxen regularly for headaches.  Her hands are shown in the image below:  Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

Explanation: This patient has typical features of irritant contact dermatitis (ICD). Clinical findings characteristic of ICD include pruritus, erythema, and scaling of the skin. As symptoms become chronic, hyperkeratosis and painful fissuring are also commonly seen. Symptoms are often worst where skin is the thinnest, at the dorsum of the hands, fingertips, and finger webs. The diagnosis is primarily clinical, but patch testing to rule out allergic dermatitis may be useful on occasion. ICD is the cause of 80% of all cases of occupational hand dermatitis. It is due to repeated exposure to irritants (eg, detergents, solvents, oxidizing agents) over time and may occur after days, weeks, or months of exposure to the irritant. ICD is especially common in patients with underlying atopic dermatitis and in health care workers who use occlusive gloves frequently. atopic dermatitis Other causes of hand dermatitis with similar features include allergic contact dermatitis, which is immune mediated, and dyshidrotic eczema, which is characterized by vesicular lesions involving the palms and soles. In practice, all of these disorders are initially managed in similar fashion with: allergic contact dermatitis dyshidrotic eczema Identification and avoidance of the offending agents Washing hands with lukewarm water and mild cleansers Frequent use of emollients Topical glucocorticoids (Choice B) Phototoxic dermatitis can be induced by systemic medications such as diuretics, antibiotics, nonsteroidal anti-inflammatory drugs, and various other drugs. The reaction consists of erythema with or without bullae and vesiculation over sun-exposed areas such as the dorsal hands, forearms, upper chest, and face. Phototoxic dermatitis (Choice C) Psoriasis is an inflammatory disorder characterized by localized plaques with erythema and scaling. It may involve the hands, but is most common at the extensor surfaces of the elbows and knees. Psoriasis (Choice D) Scabies manifests with pruritic papules, possibly with an associated scale and thin linear burrows, in the finger webs, lateral palms, wrists, ankles, and genital region. Scabies (Choice E) Tinea manuum causes annular erythema with a trailing scale on the dorsal or ventral hands. Mild itching is typically present. Classically only one hand is involved, although tinea pedis is often present as well. Tinea manuum Educational objective: Irritant contact dermatitis (ICD) is the most common cause of occupational hand dermatitis. Chronic exposure to mild irritants, such as solvents and detergents, can result in pruritus, erythema, hyperkeratosis, and fissuring of the hands. Occlusion of irritants under rubber gloves is a typical cause of ICD in health care workers. References: Hand dermatitis: review of etiology, diagnosis, and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/19429739)

A 43-Year-Old Woman Comes to the Physician for a Rash